Union Labor Health Foundation - ULHF DENTAL FUND REQUEST FORM

ULHF DENTAL FUND REQUEST FORM

Union Labor Health Foundation Children's Dental Angel Fund
Provides small grants to meet immediate dental needs of children. Applications are accepted at any time and are reviewed periodically. Only the last name of the person in need will remain confidential. Please review the guidelines prior to submitting requests.

2 Ways To Apply:

Easy Online Application Below (Please submit a pre-treatment plan via fax)
By Postal Mail or Fax

Download Application & Guidelines: In Word | In PDF

Requested by (Your Name):		Agency:
Address:		City:
State:		Zip:
Phone:		Fax:
Email:
Request for (Name):		Age/Date of Birth:
Address:		City:
State:		Zip:
Family Income:		Number of People in Houshold:
Insurance Coverage?		If yes, type of coverage:
Describe dental issues for this child and impediments to care:
Chronicity (how long):		Past or present dental provider:
Dentist to perform requested procedure(s):
How will dental service delivery be assured:
Amount requested:

= Required

We highly respect your privacy. The information you provide will not be shared with any persons or entities outside the Humboldt Area Foundation, and will only be used to keep you advised of updated information and news of relevant content to The Foundation's areas of practice. By entering your personal information, you understand that you will be added to The Foundation's contact database and may receive future emails. Read Privacy Policy